Murtagh - Chest pain Flashcards
list the immediate life threatening causes of chest pain
myocardial infarction (MI) and unstable angina (acute coronary syndromes: ACS)
pulmonary embolism
aortic dissection
tension pneumothorax
main DDx of ACS
aortic dissection, pericarditis, oesophageal reflux and spasm, biliary colic and hyperventilation with anxiety
probability diagnosis of chest pain
musculoskeletal (chest wall)
psychogenic
angina
serious disorders not to be missed for chest pain
cardiovascular:
- acute coronary syndromes
aortic dissection
- pulmonary embolism
neoplasia:
- lung cancer
- tumours of the spinal cord and meninges
severe infections:
- pneumonia/pleuritis (pleurisy)
- medications
- pericarditis
pneumothorax esp. tension
oesophageal rupture
pitfalls (often missed) for chest pain
mitral valve prolapse
osesophageal spasms
gastro-oesophageal reflux disease
biliary colic/acute cholecystitis
herpes zoster
fractured rib (e.g. cough fracture)
spinal dysfunction
muscular tear
rarities for chest pain
pancreatitis
Bornholm disease (pleurodynia)
cocaine inhalation
hypertrophic cardiomyopathy
seven masquerades checklist for chest pain
depression
anaemia
drugs (e.g. cocaine)
spinal dysfunction
is the patient with chest pain trying to tell me something?
consider functional causes, especially anxiety or panic with hyperventilation e.g. takotsubo syndrome), opioid dependancy
causes of musculoskeletal/chest wall pain
chostochondritis, muscular strains, dysfunction of the sternocostal joints and dysfunction of the lower cervical spine or upper thoracic spine, which can cause referred pain to various ares of the chest wall
red flags in acute chest pain
dizziness/syncope
pain in arms L>R, jaw
thoracic back pain
sweating
palpitations
syncope
haemoptysis
dyspnoea
pain on inspiration
pallor
past history - ischaemia, diabetes, hypertension
severe infections that could cause chest pain
pneumonia/pleurisy
pericarditis
mediastinitis
the chest pain patient who also has syncope
consider myocardial infraction, pulmonary embolus and dissecting aneurysm
the chest pain patient who also has pain on inspiration
consider pleuritis, pericarditis, mediastinitis, pneumothorax and musculoskeletal pain
the chest pain patient who also has thoracic back pain
consider spinal dysfunction, acute coronary syndromes, angina, aortic dissection, pericarditis and Gi disorders such as peptic ulcer, biliary colic/cholecystitis and oesophageal spasm
things you should notice on general appearance of the patient
evidence of atherosclerosis (senile arcus, thickened vessels), pale and sweating (MI, dissecting aneurysm or pulmonary embolus), hemiparesis (? aortic dissection)
the patient has reduced breath sounds on auscultation, hyper resonant percussion notes and vocal fremitus
pneumothorax
on auscultation, the patient has friction rub
pericarditis
on auscultation, the patient has basal crackles
cardiac failure
on auscultation, the patient has aortic diastolic murmur
proximal dissection (aortic regurgitation)
usefulness of electrocardiogram
diagnostic for ischaemia and infraction, but can show up normal in both
pericarditis on ECG
characterised by low voltages and saddle shapes ST segment elevation
pulmonary embolism on ECG
may be normal but if massive may show right axis deviation, right BBB and right ventricular strain
exercise stress test
uses a treadmill to elicit ECG change with physical exertion to diagnose myocardial ischaemia
exercise thallium scan
radionulceotide myocardial perfusion scan using thallium can complement the exercise ECG
chest x-ray
routine chest x-ray is taken on full inspiration, ask for expiration film of pneumothorax is suspected
blood glucose
tests association with diabetes
serum enzymes
damaged necrosed myocardial tissue releases cellular enzymes, which are markers of this damage:
- troponin I and troponin T (the key marker) - on arrival and 2 hours later (ADAPT trial protocol)
- creatinine kinase (CK) and creatinine kinase myocardial bound fraction (CK-MB)
- myoglobin
trasnthoracic echocardiography
can be used in the early stages of myocardial infraction to detect abnormalities in the heart wall motion, when ECGs and enzymes are not diagnostic
transoesophageal echocardiography
more sensitive and it the investigation for dissecting aneurysm (immediate diagnosis), prosthetic valves and embolisation
isotopes scanning
- technetium-99m pyrophosphate studies
- myocardium - to diagnose posterolateral myocardial infarction in the presence of bundle branch block
- pulmonary - to diagnose pulmonary embolism - gated blood pool nuclear scan (radio nucleotide ventriculography) - this scan tests left ventricular function at rest and exercise in patient with myocardial ischaemia
angiography (arteriography)
angiography, including CT angiogram, should be selective:
1. coronary - to evaluate coronary arteries
2. pulmonary - to diagnose pulmonary thromboembolism
3. coronary computed tomograph
4. MRI
coronary artery disease includes
acute coronary syndromes - unstable angina and myocardial infarction
stable angina
other variants of angina
